Endoscopic submucosal tunnel dissection for large superficial esophageal squamous cell neoplasms

Figure 1 Indications for endoscopic resection by 2012 Japan Esophageal Society guidelines.

Figure 2 Schema of endoscopic submucosal tunnel dissection. A: Evaluating and delineating the neoplasm; B: After marking the lesion margin, mucosal incision was performed in the anal-oral sequence; C: A submucosal tunnel was created from the oral to anal side; D: Lateral resection with an insulated-tip knife for complete removal of the lesion; E: Preventive coagulation on artificial ulcer.

Figure 3 Endoscopic submucosal tunnel dissection with a single triangle-tip knife. A: Lugol staining to delineate the lesion, occupying almost half of the esophageal lumen. The margin was marked by argon plasma coagulation; B, C: Anal and oral incision was performed successively with a triangle-tip (TT) knife. Water jet helped entry into the submucosal tunnel; D: Submucosal tunnel was created from the oral to anal side; E: Lateral resection with a TT knife from the oral to anal side until reaching the anal incision; F: Complete en bloc resection was achieved in 52 min; G: The specimen, around 55 mm × 35 mm in size, was retrieved. Histopathological examination revealed a microinvasive squamous carcinoma limited in the lamina propria mucosa, free of lateral and vertical margin.

Figure 4 Double-tunnel endoscopic submucosal tunnel dissection for circumferential superficial esophageal neoplasms. A: An 8 cm circumferential superficial esophageal cancer was showed by iodine staining, at 28–36 cm from the incisors; B: Circular incisions were successively performed at the anal and oral margins after marking; C, D: Two submucosal tunnels were created opposite each other. Two tunnels nearly covered the whole esophageal lumen, and the borders were narrow enough to be resected easily; E: A 14 cm retrievable, fully-covered esophageal stent was placed to prevent postoperative stenosis. F: The lesion was resected circumferentially, about 60 mm in length. From Zhai et al[20].

Figure 5 Proposed flow diagram of postoperative stricture prevention for superficial esophageal squamous cell neoplasms after endoscopic resection.